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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206664
Report Date: 12/16/2022
Date Signed: 12/16/2022 09:32:46 AM

Document Has Been Signed on 12/16/2022 09:32 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
FACILITY NAME:BURRUS ADULT RESIDENTIALFACILITY NUMBER:
107206664
ADMINISTRATOR:BURRUS, LINDAFACILITY TYPE:
735
ADDRESS:157 N. ARMSTRONGTELEPHONE:
(559) 321-8737
CITY:CLOVISSTATE: CAZIP CODE:
93611
CAPACITY: 6CENSUS: 3DATE:
12/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:20 AM
MET WITH:Linda Burrus, LicenseeTIME COMPLETED:
09:45 AM
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On 12/16/22, Licensing Program Analyst (LPA) M. Yang arrived unannounced at the above facility to conduct an Annual Inspection- Infection Control. LPA was greeted by Linda Burrus, Licensee. LPA introduced self, stated the purpose of the visit and was granted entry. Upon entry staff was observed not wearing facial covering. Visitor log in/temperature check observed upon entry. LPA conduct tour with Licensee. There were two clients were present during the tour.

Facility has one entrance/exit point. Social distancing is maintained in the common and dining areas. LPA observed COVID-19 related signs and cough etiquette posting. Food supply was checked and there appeared to be an adequate supply. LPA observed fire extinguishers with a service date of:11/22/21. LPA observe a 30-day PPE supplies. LPA checked residents’ locked medications.

Trash bin in bathrooms was observed with no lid. LPA observed hand washing posting by bathroom sinks. LPA toured all bedrooms. All 4 bedrooms are single occupant and observed to be adequately furnished and lit. The exterior tour was conducted. The exterior tour was conducted. Side gate was self-closing and self-latching. Staff records were reviewed for good health and infection control training. All residents have updated emergency contact information.

A deficiency is being cited on the attached 809D in accordance to California Code of Regulations, Title 22, Division 6.

Exit interview was conducted. Please submit the following forms/information to Fresno CCL by: 12/22/22. Requested forms/ information: Lic 308, Lic 500, Lic 610D, Lic 9020, and Lic 9282. A copy of this report and appeal rights was provided to Licensee.

SUPERVISORS NAME: Melinda Hoffmann
LICENSING EVALUATOR NAME: Mai Yang
LICENSING EVALUATOR SIGNATURE: DATE: 12/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/16/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/16/2022 09:32 AM - It Cannot Be Edited


Created By: Mai Yang On 12/16/2022 at 09:14 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: BURRUS ADULT RESIDENTIAL
FACILITY NUMBER: 107206664

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/16/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80064(a)(3)
80064(a)(3) Administrator - Qualifications and Duties (a) The administrator shall have the following qualifications: (3) Knowledge of and ability to comply with applicable law and regulation

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, Fire Extinguisher has a service date of 11/22/21, which poses an immediate health and safety risk to the clients.
POC Due Date: 12/19/2022
Plan of Correction
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Licensee states fire extinguisher will be replaced or serviced with a current date. Proof of correction will be submitted to the CCL office by the 12/19/22.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Melinda Hoffmann
LICENSING EVALUATOR NAME:Mai Yang
LICENSING EVALUATOR SIGNATURE:
DATE: 12/16/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/16/2022


LIC809 (FAS) - (06/04)
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